Children are much more likely to hide their pain than to exaggerate it, says Dr. Finley. “If a child thinks that admitting to having pain means he’s going to get a needle, he’s going to have to stay in hospital, his parents are frightened or upset, or that you’re going to manipulate his broken arm to make it hurt more, then he’s not going to tell you,” he adds. Therefore, it is important to directly ask about pain.
3 Ps of treatment
Effective pain treatment generally incorporates the “3 Ps:” psychological intervention, physical therapy, and pharmacotherapy.
Psychological interventions such as slow rhythmic breathing, distraction, or the use of imagery can be very effective.
Common physical therapy strategies include applying heat or cold to reduce pain or swelling from bruises or insect stings, massaging a stubbed toe, or giving an infant a sweet solution to suck during a needle poke.
Children are treated with four main types of pharmacotherapy: nonopioids, opioids, topical anesthetics, and adjuvant therapies.
OTC non-opioids such as acetaminophen or a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen are commonly used to treat headache, toothache, and earache. Ibuprofen, which has an anti-inflammatory effect, is used for musculoskeletal pain such as arthritis and sports injuries. “For earache, most children do fine with acetaminophen or ibuprofen,” says Dr. Kaplan. These drugs are safe for occasional use in children, notes Dr. Taddio, adding that they may be used to treat a fever or sore arm that occurs after a vaccination shot, but they are not effective for pain at the time of the injection.
The opioid morphine may be prescribed after tonsillectomy, hernia repair, or treatment of a fracture. Morphine can be used safely when given in appropriate doses with monitoring for respiratory depression, says Dr. Finley. Prescribing acetaminophen or ibuprofen along with morphine can improve pain relief and lessen the amount of morphine that is needed. Addiction is extremely rare in children under 12, Dr. Kaplan notes, although teenagers may be prone to experiment with drugs, and some physicians advise against codeine use in children due to fluctuating serum levels and the potential for unintentional overdose.
Three topical OTC anesthetics are available in Canada: lidocaine/prilocaine (EMLA), amethocaine (Ametop), and liposomal lidocaine (Maxilene). These drugs are effective for pain associated with injections, catheter insertions, or drawing blood, and are especially helpful for hospitalized children who undergo multiple procedures. However, the use of these creams has not yet become widespread outside the hospital setting, observes Dr. Taddio.
Differences in treating children
Children are not small adults. As they grow and develop, they undergo substantial changes that influence the efficacy, toxicity, and dosing regimens of medicines, says Jessika Truong, BScPharm, a pharmacist in hematology-oncology at The Montreal Children’s Hospital. It is important to consider a child’s age, medical problems, pain intensity, and previous pain experience, and choose the analgesic and route of administration that provides rapid, effective relief, while being aware of potential side effects. The dose may have to be adjusted, depending on the initial response to a drug.
Pharmacists may have to prepare special drug formulations when young children require smaller doses than are commercially available. Pharmacists can also advise parents how to mask the bad taste of a medicine. A liquid medicine can be combined with a small amount of juice or milk, or a pill can be crushed and combined with a small amount of jam or banana. For older children, tablets may be dipped into food. A child may be given tasty food before or after the medicine.
Resources for parents
References
1. Jacobson S. Common Medical Pains. Pediatr Child Health 2007;12(2):105-109
2. Ramag-Morin PL and Gilmour H. Chronic pain at ages 12 to 44. Statistics Canada,Catalogue No. 82-003-XPE, Health Reports, Vol. 21, No. 4, December 2010 Available
3. Stevens BJ et al. Epidemiology and management of painful procedures in children in Canadian hospitals. CMAJ 2011;183:E403-E410 Available at:
http://www.cmaj.ca/ cgi/reprint/183/7/E403 Accessed April 22, 2011.
4. Taddio A et al. Reducing the pain of childhood vaccination: and evidence-based clinical practice guideline (summary). CMAJ 2010;182(18):1989-1995. Available at:
http://www.cmaj.ca/cgi/reprint/182/18/1989 Accessed April 22, 2011.
This article first appeared in Talking Points: Pain Management and is reprinted with permission from Rogers Healthcare Group and CanadianHealthcareNetwork.ca.